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Elías Freyr Guðmundsson discusses his recent study on coronary heart disease
April 12, 2022
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In Conversation: Predicting Coronary Heart Disease

Welcome to The Sidebar, Elías! Could you tell us a bit about yourself?

After graduating as a biologist, I worked at the Icelandic Marine Research Institute, and I particularly enjoyed going out to sea to collect samples for research. I later found that my scientific interest revolved more around health, so I decided to pursue a master’s degree in epidemiology at the University of Melbourne in Australia. I have often had to explain what epidemiologists do but since the pandemic, most people have become quite familiar with the term.

But epidemiology is not just about infectious diseases, it is also the study of the distribution and risk factors of health-related states and events. After completing my studies, I worked for ten years at the Icelandic Heart Association analyzing data from population-based cohort studies. Such work aims to improve understanding of risk factor associations, thus generating knowledge that may ultimately improve public health.  

You recently had a paper published on the possibility of carotid artery atherosclerosis and the presence of coronary artery calcium to predict future coronary heart disease events. Could you tell us a little more about it?

The paper is based on data from the population based REFINE-Reykjavik study which is conducted by the Icelandic Heart Association. Participants in this study underwent detailed examinations which allowed us to investigate atherosclerosis in individuals who do not have a previous history of heart disease.

Atherosclerosis is the build-up of fats, cholesterol and other substances within the arterial walls which leads to narrowing of the arteries and reduced blood flow. The plaques that accumulate can eventually stop blood flow or rupture, causing an acute event such as a heart attack or a stroke.

In this study, we were able to investigate associations between atherosclerosis in two distinct locations in the body, in the carotid arteries in the neck and coronary artery calcium in the heart. Information on those associations have been lacking for individuals without a history of heart disease.

The benefit of imaging the carotid arteries using ultrasound is that it does not involve exposure to radiation, whereas this is the case for assessing coronary artery calcium.

Therefore, it can be of value if a non-invasive assessment of atherosclerosis in the carotid arteries could provide information on atherosclerosis in the heart, as this may help identify individuals at risk of serious events.

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What was the main takeaway from your paper?

We found that in individuals with no prior history of heart disease that the presence of carotid plaque was strongly associated with the presence and extent of calcium in the coronary arteries. Furthermore, we found that carotid plaque assessment improved prediction of new coronary events over conventional risk calculators. A problem with current risk calculators is that they perform worse for prediction in females, falsely categorizing too many as having low risk.

We also found that there was a gradient in observed risk across carotid plaque categories in females who were otherwise classified as having low risk according to conventional calculators. This offers clues that carotid ultrasound assessment may be used to improve risk classification.

Almost 50% of patients with a sudden cardiac event do not experience warning clinical symptoms. That’s a really high number! Can you tell us how this study adds to the discussion around current cardiovascular prevention risk assessment approaches?

Yes, it is true that many individuals who experience an acute coronary event have not had symptoms up until that point. This study adds information on how risk calculators and screening could potentially be improved in order to identify people at increased risk of suffering a largely preventable outcome, such as a heart attack.  

Ultrasounds of carotid plaque may therefore be useful for refined risk prediction and aid in deciding who needs additional assessments to prevent detrimental outcomes.

This may also enable earlier implementation of lifestyle modifications and pharmacological interventions for primary prevention. We are still learning a lot about risk prediction in heart disease and this needs to be investigated and validated in other populations as well.

Sidekick has some ongoing and planned cardiovascular projects with the National University Hospital of Iceland. What can you tell us about that?

The projects are a close collaboration between Sidekick and the nurses and doctors of the cardiology unit at the National University Hospital of Iceland. The overarching aim is to improve patients’ quality of life and access to care in three types of cardiovascular diseases: heart failure, coronary artery disease, and atrial fibrillation.

The projects will test digital care solutions to remotely monitor symptoms, and provide lifestyle- and disease-management support to patients. The solutions are being integrated into standard treatment and are studied for feasibility, patient satisfaction, and effectiveness.

So far, we have conducted two small feasibility studies for heart failure and coronary artery disease which showed encouraging results in terms of user satisfaction, engagement, and outcomes. As a result, we will plan larger studies to test the solutions.

Currently we are conducting a large randomized controlled trial (RCT) to test the Sidekick solution in patients with heart failure. The study has a control group which receives the standard of care and an intervention group that in addition to the standard care receives Sidekick’s digital solution. This will allow us to compare the approaches and determine effectiveness. Digital care technologies have the potential to improve reach, access, and quality of chronic disease care while reducing the burden on health care systems.

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Bronwyn Hemus

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